Care Management - Nurse, Senior

Care Management – Overview

The Care Management team independently manages complex and high‑risk care management cases by applying advanced clinical judgment to assess medical necessity, develops cost‑effective care plans, supports quality outcomes aligned with benefit and contract requirements, and coordinates care with providers, medical directors, and interdisciplinary teams. The role requires ongoing reassessment, awareness of healthcare trends and clinical guidelines, and participation in a rotating evening and weekend on‑call schedule.

Responsibilities

• Work with minimal supervision to manage complex care management cases
• Apply advanced clinical judgment to assess medical necessity and appropriateness of care
• Design and implement treatment and care plans that promote quality, cost‑effective outcomes aligned with benefit and contract requirements
• Coordinate discharge planning activities for complex and high‑risk cases
• Determine appropriateness of referrals to care management and specialty programs
• Collaborate with providers, medical directors, and interdisciplinary teams to support member treatment plans and care continuity
• Evaluate member health behaviors, cultural influences, and belief systems to identify barriers to care
• Contribute clinical input to medical directors and support informed decision making
• Continuously improve outcomes by anticipating barriers and adjusting plans of care based on reassessment, clinical changes, and guideline updates
• Maintain current knowledge of healthcare service trends, regulations, and clinical practice guidelines
• Work evenings and weekends as part of rotating on‑call schedule
• Perform other duties as assigned

Qualifications

• Associate Degree in Nursing required or master’s degree in a relevant field for non‑RN licensure
• Bachelor of Science in Nursing is preferred
• 5 years of experience in nursing, healthcare, or a related clinical field
• 3 years of managed care experience preferred
• Certified Case Manager (CCM) is preferred
• Ability to independently assess, evaluate, and interpret complex clinical information and care plans
• Advanced knowledge of evidence‑based clinical practice guidelines, particularly for chronic conditions
• Demonstrated competence in care management functions and standards of practice
• Knowledge of community resources, treatment options, home health services, funding sources, and specialty programs
• Working knowledge of regulatory and accreditation standards including CMS, DHCS, URAC, NCQA, DMHC, MHPAEA, and CA SB 855 is preferred
• Knowledge of coordination of care, government and commercial regulations, prior authorization processes, and level of care and length of stay criteria is preferred

Hybrid Virtual Work

This role allows employees to work virtually full‑time; however, employees will be expected to come to the office based on business needs.

Job Information

• Job Identification:
• Job Category: Healthcare Services and Operations
• Job Schedule: Full time
• Locations: El Dorado Hills, CA; Long Beach, CA; Lodi, CA; Oakland, CA; Rancho Cordova, CA; Redding, CA; San Diego, CA; Woodland Hills, CA
• Pay Range for California: $90,860.00 to $136,290.00
• Pay Range for Bay Area: $102,424.00 to $153,636.00
• Role can be filled by a candidate requiring sponsorship: No

Physical Requirements

Office Environment – roles involving part to full time schedule in an office environment. Based in physical offices and work from home office/deskwork – activity level: sedentary, most of work day.

Equal Employment Opportunity

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.